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SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> NGPARTY❑ <br /> OWNER I OPERATOR Ir L` <br /> FACILm NAME MAR 1 8 ZOOZ <br /> iz <br /> $READDRESSs wNwnn.r n (�JY-mLTL.su.«Nmrr <br /> ENVifiUIIi i;'_i`J gyp E!1 TH <br /> Mailing Address (If Different from Site Address) PERP ii 1/�"kh vlv s <br /> CITY STATE ZIP <br /> PHONE 91 ExT• APN# LAND USE APPtJCATION# <br /> PHONE#Z EXT. BOS DISTRICT LOCATION CODE <br /> CONTRACTOR I SERVICE REQUESTOR <br /> BIWNG PARTY 9--- <br /> REQUESTOR <br /> C-� P,-L.L EZT. <br /> PHONE# <br /> BUSINESS NAME (4px 17 r7 <br /> VZ I FAx#/L 7 <br /> MAILING ADDRESS _ <br /> n _ LP ' <br /> BILLING ACKNOWLEDGEMENT: I,the undersigned property or business owner,operator or authorized agent of same, acknowledge that all site and/or project specfc <br /> PUBLIC HEALTH SERVICES E.WRGNIAENTAL HEALTH ONISIGN hourly charges assoaated with this project or ac vity Will be billed to me or my business as identified on this forth. <br /> I also certify that I have prepared this appFication and that the work to be performed will be done in accordance with all SAN JOAQUIN COUNTY Ordinance Codes,Standards,STATE and <br /> FEDERAL laws. �/�G/� l <br /> L DATE: <br /> APPLICANT SIGNATURE: -` <br /> OPERATOR/ GEA ❑ OTHER AUTHORIZED AGENT <br /> PROPERTY I BUSINESS OWNER Cl Title <br /> NAPax wr is rad the 811 sr:PARTY P00f of wrhorfzatfan to sign b rpuind <br /> AUTHORIZATION TO RELEASE INFORMATION:When applicable,I,the owner or operator of the property located at the above she address,hereby authorize the release of <br /> any and all results,geotechnical data and/or envimnmentaUsite assessment information to the SAN JOAGUW COUNTY PUBLIC HEALTH SERVICES ENVIRONMENTAL HEALTH DIVISION as soon <br /> as it is available and at the same time it is provided to me or rrry representative. <br /> TYPE OF SERVICE REQUESTED: <br /> COMMENTS: 5 <br /> INSPECTORS SIGNATURE: CONTRACTOR'S SIGNATURE: <br /> APPROVED BY. EidPI-CYEEft: S 3 O DATE <br /> ASSIGNED TO: EmPLOYEE M DATE: <br /> Date Service Completed (if already completed): <br /> SERVICE CODE: 9 -P!E• O� <br /> Fee Amount: ( O Amount Paid Payment Date <br /> Payment Type <br /> Invoice# Check# Received By: <br />